MEDICARE: SHAN MA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT35938-TLG	CA

General Provider Information

NPI Number	:	1174175129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAN MA OD

Provider Business Mailing Address
First Line	:	8230 MIRA MESA BLVD STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2625
Country	:	US
Telephone Number	:	858-566-6670
Fax Number	:

Provider Business Practice Location Address
First Line	:	8230 MIRA MESA BLVD STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2625
Country	:	US
Telephone Number	:	858-566-6670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	02/25/2026

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